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With reforms to the nation’s healthcare delivery moving into place, increasing emphasis is being put on so-called midlevel practitioners – physician assistants and nurse practitioners—who can help ease the shortage of MDs. Both kinds of professionals are in demand and additional U.S. training programs and dollars are being allocated to turn out more PA and NP graduates.

Some states, too, are liberalizing rules about supervision and scope of practice, so that new patients who will be ensured coverage under the Accountable Care Act will have access to care.

And as more physicians retire or think about selling their practices to hospitals, these midlevel practitioners are seeing opportunity in taking their place as small business people.

While not a large movement, a number of physician assistants have opened their own practices (in states that permit it) or are considering it; it is a big topic on online forums. Mostly the practices are small and specialty-focused, but others have employees and provide comprehensive family care.

One of the latter is Scott Jonason, PA-C, president of Lacamas Medical Group in Camas, Wash. In his family practice and urgent care clinic he has 27 employees. After a few rough years after he opened the doors in 2003, the practice is thriving and is a recognized member of the local medical community.

He decided to take the plunge when a medical practice left town, leaving a building vacant and the town “without much in the way of healthcare.” He gave a physician a 10% share of the business at the outset (laws vary about how much a PA can own) and hired one other PA. He now has five providers seeing patients.

“Because Washington is so PA-friendly we never had much issue from patients and we’ve never had any problems as a PA-owned and operated clinic,” he says.

Jonason said he never doubted his decision to go into family practice, despite the fact it takes more staff, money and equipment. “I’ve always been in family practice and love primary care. I enjoy infants to the elderly and see a little bit of everything.”

He does say that he limits his role to practicing medicine – not to “micro managing. I don’t try to do everything -- although I know how everything works. I hire people who are smarter than me and let them do their jobs.”

He also brought in a physician as a partner last year, who has “taken some of the weight off my shoulders. Somebody else has a little skin in the game.”

Ownership structures can be complex and the American Academy of Physician Assistants has information available to members on the various state laws which determine what entities may own medical practices. In some states, PAs may own them outright as a licensed professional or through a professional limited liability corporation; other states only allow minority ownership.

There remains some pushback from physicians about nurse- and PA-led medical practices. Recently the Academy of Family Physicians issued a report saying perceived shortages of doctors don’t justify more independent practices.

Insurance woes

J. Michael Jones, MPAS-C, who owns Pacific Rim Headache Center in Anacortes, Wash., can attest to the fact that starting up a business was a big headache. Many banks, for instance, aren’t aware that PA-owned clinics are legal.

A big bank was ready to write him a check to open the business when it reneged at the last minute. “They just assumed I was a doctor. I told them I’m not a physician, I’m a PA and we went round and round for almost four months.” He ended up using another bank.

He also had lots of pushback from insurance companies – “who look for reasons not to pay you if you’re not a well-established clinic.” And he’s had billing problems that have impacted his cash flow.

But Jones says he is pleased to be fulfilling his dream of a specialty headache clinic. “I worked in headache disorders for 30 years. It was a major motivation to create a practice centered on headache – it wasn’t financial, but to create a place where patients can be served better.”

Since opening in 2011, the clinic, which now has a satellite office in Bellingham, Wash., has become the second-business headache, migraine and face pain practice in the state.

Also in Bellingham is PrimeCare PLLC, a clinic that specializes in substance abuse. Dennis Newsome, MPAS, PA-C, clinic director, opened it in 2011 after previously operating a house call business.

He has three sponsoring physicians who work with him and his wife and daughter work in the business.

He echoes the fact that starting up can be rough, especially with insurance companies that may not understand the physician assistant credential. “Our name doesn’t necessarily show what we do. People have a mental block about supervision – they expect to have someone looking over your shoulder.”

Newsome decided to forgo insurance and make it a cash-only business, although he helps patients with reimbursement forms.

Chinyene Eze, MS, PA-C, operates a primary care clinic that also specializes in medical weight loss -- the Eze Family Health Center in Waldorf, Maryland. Like Newsome, she provides extended office hours and prides herself on being accessible to patients. “I have a cell phone where people can reach me after hours. Being focused on the patient, having good customer service is essential.”

Eze, a licensed practitioner in Maryland, Virginia, Washington D.C. and Florida, said a friend in who opened his third urgent care center was her inspiration to go on her own last November. “I’d been thinking about it awhile and my husband is a businessman. I do think it is becoming a trend.”

Joyce Routson is a journalist on the HEALTHeCAREERS.com News Beat Team who has written about healthcare, labor and recruiting for a number of publications including the Contra Costa Times, NurseWeek and Staffing Industry Report. A resident of the San Francisco Bay Area, she also works as an editor at Industry Intelligence Inc.